Robotic assisted clip applier

ABSTRACT

A medical instrument comprising an end effector comprising a first jaw configured to be repositionable with respect to a second jaw, the first and second jaws removably mounted to an open-ended occlusion clip, the end effector configured to configured to be removably coupled to an open-ended occlusion clip with a pair of terminal ends and first and second robotic arms, and wherein the end effector includes at least one of a cavity and a projection configured to be engaged by at least one of the first and second robotic arms.

INTRODUCTION TO THE INVENTION

The present disclosure is directed to medical instruments and, morespecifically, to an applier that may be used to apply a left atrialappendage occlusion clip.

It is a first aspect of the present disclosure to provide a medicalinstrument comprising an end effector comprising a pair ofrepositionable jaws operatively coupled to an open-ended occlusion clipdevoid of a handle control.

In a more detailed embodiment of the first aspect, the end effectorincludes a line concurrently mounted to the open-ended occlusion clipand the pair of repositionable jaws. In yet another more detailedembodiment, the line comprises at least a first line and a second line,the first line is concurrently mounted to the open-ended occlusion clipand a first of the pair of repositionable jaws, the second line isconcurrently mounted to the open-ended occlusion clip and a second ofthe pair of repositionable jaws, and the first and second lines arerepositionable to selectively dismount the first line from at least oneof the open-ended occlusion clip and the first of the pair ofrepositionable jaws, and to selectively dismount the second line from atleast one of the open-ended occlusion clip and the second of the pair ofrepositionable jaws. In a further detailed embodiment, the end effectorincludes pulleys operatively coupled to at least one of the pair ofrepositionable jaws. In still a further detailed embodiment, the firstof the repositionable jaws is mounted to a first of the pulleys, thesecond of the repositionable jaws is mounted to a second of the pulleys,and a line engages the first and second pulleys. In a more detailedembodiment, the first repositionable jaw is mounted to a first and athird of the pulleys, the second repositionable jaw is mounted to asecond and a fourth of the pulleys, and a line engages the first,second, third, and fourth pulleys. In a more detailed embodiment, eachof the pair of repositionable jaws includes a channel configured toreceive a deployment line, the deployment line operatively coupled toone of the pair of repositionable jaws and the open-ended occlusionclip. In another more detailed embodiment, the end effector includes atleast one of a cavity and a projection configured to be engaged by arobotic grasper. In yet another more detailed embodiment, the endeffector includes at least one of a plurality of projections and aplurality of cavities configured to be engaged by a robotic grasper. Instill another more detailed embodiment, the open-ended occlusion clipcomprises: (i) a first elongated occlusion arm; (ii) a second elongatedocclusion arm; (iii) a first elongated biasing arm coupled to a distalportion of the first elongated occlusion arm; and, (iv) a secondelongated biasing arm coupled to a distal portion of the secondelongated occlusion arm, where a proximal portion of the first elongatedbiasing arm is coupled to a proximal portion of the second elongatedbiasing arm, where the first elongated occlusion arm extends parallel tothe first elongated bias arm along a majority of its length, and wherethe second elongated occlusion arm extends parallel to the secondelongated bias arm along a majority of its length.

It is a second aspect of the present invention to provide a medicalinstrument comprising an end effector comprising a first jaw configuredto be repositionable with respect to a second jaw, the first and secondjaws removably mounted to an open-ended occlusion clip, the end effectorconfigured to configured to be removably coupled to an open-endedocclusion clip with a pair of terminal ends and first and second roboticarms, and wherein the end effector includes at least one of a cavity anda projection configured to be engaged by at least one of the first andsecond robotic arms.

In a more detailed embodiment of the second aspect, the end effectorfurther comprises at least a first line and a second line, the firstline is concurrently mounted to the open-ended occlusion clip and thefirst jaw, the second line is concurrently mounted to the open-endedocclusion clip and the second jaw, and the first and second lines areselectively repositionable to dismount the first and second lines fromthe open-ended occlusion clip and the first and second jaws. In yetanother more detailed embodiment, the end effector includes pulleysoperatively coupled to the first and second jaws. In a further detailedembodiment, the first jaw is mounted to a first of the pulleys, thesecond jaw is mounted to a second of the pulleys, and a line engages thefirst and second pulleys. In still a further detailed embodiment, theopen-ended occlusion clip comprises: (i) a first elongated occlusionarm; (ii) a second elongated occlusion arm; (iii) a first elongatedbiasing arm coupled to a distal portion of the first elongated occlusionarm; and, (iv) a second elongated biasing arm coupled to a distalportion of the second elongated occlusion arm, where a proximal portionof the first elongated biasing arm is coupled to a proximal portion ofthe second elongated biasing arm, where the first elongated occlusionarm extends parallel to the first elongated bias arm along a majority ofits length, where the second elongated occlusion arm extends parallel tothe second elongated bias arm along a majority of its length.

It is a third aspect of the present invention to provide a method offabricating an end effector that includes a first jaw repositionablewith respect to a second jaw, the first and second jaws removablycoupled to an open-ended occlusion clip with dual terminal ends, themethod comprising: (a) detachably mounting the open-ended occlusion clipto the first and second jaws using a first line; (b) threading at leastone pulley mounted to each of the first and second jaws with a secondline, where the line extends from a first pulley of the first jaw to asecond pulley of the second jaw; and, (c) directing the first and secondlines through a portion of the end effector.

In a more detailed embodiment of the third aspect, the act of threadingat least one pulley includes threading multiple pulleys associated witheach of the first and second jaws to create a double tackleconfiguration. In yet another more detailed embodiment, the act ofdetachably mounting the open-ended occlusion clip includes threading thefirst line through a plurality of loops extending through at least oneof the first and second jaws, the plurality of loops being mounted tothe open-ended occlusion clip.

It is a fourth aspect of the present invention to provide a necrosisclip and applier comprising: (a) an open-ended necrosis clip comprisinga first beam longitudinally aligned with and spaced apart from a secondbeam, the first beam operatively coupled to and longitudinally alignedwith a third beam, the second beam operatively coupled to andlongitudinally aligned with a fourth beam, where the third and fourthbeams are coupled to one another, and where the first and second beamseach include an unattached terminal end; (b) an end effector including afirst jaw and a second jaw repositionably mounted to a housing, thefirst and second jaws operatively coupled to at least a gun tacklepulley configuration utilized to reposition at least one of the firstand second jaws with respect to one another, where the first and secondjaws are detachably mounted to the open-ended necrosis clip; and, (c) arobotic coupling feature associated with the end effector and configuredto be engaged by a robotic surgical instrument to removably couple therobotic surgical instrument to the end effector.

In a more detailed embodiment of the fourth aspect, the robotic couplingfeature includes at least one of a cavity and a projection configured tobe engaged by the robotic surgical instrument. In yet another moredetailed embodiment, the end effector includes a first detachment linein operative engagement with the first jaw of the end effector and thenecrosis clip, and the end effector includes a second detachment line inoperative engagement with the second jaw of the end effector and thenecrosis clip. In a further detailed embodiment, the first jaw and thesecond jaw each include a channel configured to receive at least one ofthe first detachment line and the second detachment line. In still afurther detailed embodiment, the first detachment line extends through afirst loop coupled to the first jaw when the open-ended necrosis clip isdetachably mounted to the first jaw, the second detachment line extendsthrough a second loop coupled to the second jaw when the open-endednecrosis clip is detachably mounted to the second jaw, the firstdetachment line does not extend through the first loop coupled to thefirst jaw when the open-ended necrosis clip is detached from to thefirst jaw, and the second detachment line does not extend through thesecond loop coupled to the second jaw when the open-ended necrosis clipis detached from to the second jaw. In a more detailed embodiment, thefirst jaw includes a first channel configured to receive the firstdetachment line, the first jaw includes a first orifice configured toreceive the first loop, the second jaw includes a second channelconfigured to receive the second detachment line, and the second jawincludes a second orifice configured to receive the second loop. In amore detailed embodiment, at least the gun tackle pulley configurationincludes a first pulley, a second pulley, and a third pulley, the firstjaw is mounted to the first pulley and the third pulley, the second jawis mounted to the second pulley, and the line is fixedly coupled to thesecond jaw and repositionably engages the first pulley, the secondpulley, and the third pulley. In another more detailed embodiment, atleast the gun tackle pulley configuration includes a first pulley, asecond pulley, a third pulley, and a fourth pulley, the first jaw ismounted to the first pulley and the third pulley, the second jaw ismounted to the second pulley and the fourth pulley, and the line isfixedly coupled to the first jaw and repositionably engages the firstpulley, the second pulley, the third pulley, and the fourth pulley. Inyet another more detailed embodiment, the first jaw pivotally engagesthe second jaw.

It is a fifth aspect of the present invention to provide a method ofdeploying an occlusion clip comprising: (a) inserting an open-endedocclusion clip with dual terminal ends removably mounted to an endeffector through at least one of an incision and a trocar, the endeffector devoid of a handle control, the open-ended occlusion clip andthe end effector operatively coupled to one another prior to insertioninto and through at least one of the incision and the trocar; (b)repositioning the end effector using a first robotic tool to repositionthe open-ended occlusion clip so the open-ended occlusion clip isinterposed by a portion of a left atrial appendage between a base and atip of the left atrial appendage without needing to pass a tip of theleft atrial appendage between opposing clamping surfaces of theopen-ended occlusion clip and without needing to pierce the left atrialappendage; (c) clamping the left atrial appendage with the open-endedocclusion clip to cause necrosis to the left atrial appendage byrepositioning a second robotic tool with respect to the end effector;(d) discontinuing operative coupling between the open-ended occlusionclip and the end effector; and, (e) withdrawing the end effector throughat least one of the incision and the trocar.

In a more detailed embodiment of the fifth aspect, the inserting stepoccurs during at least one of an open sternotomy, a left thoracotomy, aright thoracotomy, a left port procedure, a right port procedure, asubxiphoid approach, and a transdiaphragmatic approach. In yet anothermore detailed embodiment, the method further includes insufflating athoracic space prior to the inserting step. In a further detailedembodiment, the method further includes making an incision as part of aprocedure comprising at least one of an open sternotomy, a leftthoracotomy, a right thoracotomy, a left port procedure, a right portprocedure, a subxiphoid approach, and a transdiaphragmatic approach, inaddition to introducing a trocar through the incision. In still afurther detailed embodiment, a first line is operatively coupled the endeffector. In a more detailed embodiment, the end effector includes afirst jaw operatively coupled to the open-ended occlusion clip, the endeffector includes a second jaw operatively coupled to the open-endedocclusion clip, and repositioning the end effector to reposition theopen-ended occlusion clip includes tensioning the first line to causeincreased spacing between the first jaw and the second jaw. In a moredetailed embodiment, the method further includes grasping the leftatrial appendage concurrent with repositioning the end effectordeployment device to reposition the occlusion clip so the open end ofthe open-ended occlusion clip is interposed by the portion of the leftatrial appendage. In another more detailed embodiment, the methodfurther includes repeating the repositioning and clamping steps prior tothe disengaging step. In yet another more detailed embodiment, themethod further includes confirming a clamping position of the open-endedocclusion clip is operative to cause necrosis to the left atrialappendage using at least one of visualization and a transesophagealechocardiogram. In still another more detailed embodiment, the insertingstep includes inserting the open-ended occlusion clip and the endeffector through the trocar, the withdrawing step includes withdrawingthe end effector through the trocar, and the trocar comprises a twelvemillimeter or less diameter cross-section.

It is a sixth aspect of the present invention to provide a method ofdeploying a necrosis clip comprising: (a) inserting an open-endednecrosis clip having dual terminal ends through a trocar, the open-endednecrosis clip removably mounted to an end effector at least partiallyincluding at least a gun tackle pulley configuration; (b) repositioningthe end effector using a robotic arm to spatially reposition theopen-ended necrosis clip proximate a portion of a left atrial appendage;(c) opening the open-ended necrosis clip using at least the gun tacklepulley configuration of the end effector to allow an open end of theopen-ended necrosis clip to be interposed by a portion of a left atrialappendage, the portion of the left atrial appendage being between a baseand a tip of the left atrial appendage, without passing the tip of theleft atrial appendage between opposing clamping surfaces of theopen-ended necrosis clip; (d) repositioning the end effector using thefirst robotic tool so the portion of the left atrial appendageinterposes the opposing clamping surfaces of the open-ended necrosisclip; (e) clamping the left atrial appendage in an initial positionbetween the opposing clamping surfaces of the open-ended necrosis clipby repositioning a second robotic tool; (f) assessing the operability ofthe open-ended necrosis clip in the initial position to cause necrosisof the left atrial appendage; and, (g) repositioning the open-endednecrosis clip to a subsequent position, different from the initialposition, where the left atrial appendage is clamped between theopposing clamping surfaces of the open-ended necrosis clip, whererepositioning the open-ended necrosis clip from the initial position tothe subsequent position is repeatable without affecting the structuralintegrity of the left atrial appendage.

In a more detailed embodiment of the sixth aspect, the method furtherincludes disengaging the open-ended necrosis clip from the end effectorpost initiation of necrosis of the left atrial appendage tip, andwithdrawing the end effector through at least one of the incision andthe trocar post disengaging the open-ended necrosis clip from the endeffector. In yet another more detailed embodiment, the inserting stepoccurs during at least one of an open sternotomy, a left thoracotomy, aright thoracotomy, a left port procedure, a right port procedure, asubxiphoid approach, and a transdiaphragmatic approach. In a furtherdetailed embodiment, the method further includes insufflating a thoracicspace prior to the inserting step. In still a further detailedembodiment, the method further includes making an incision as part of aprocedure comprising at least one of an open sternotomy, a leftthoracotomy, a right thoracotomy, a left port procedure, a right portprocedure, a subxiphoid approach, and a transdiaphragmatic approach, andintroducing a trocar through the incision. In a more detailedembodiment, the method further includes grasping the left atrialappendage concurrent with repositioning the end effector deploymentdevice to reposition the necrosis clip so the open end of the open-endednecrosis clip is interposed by the portion of the left atrial appendage.In a more detailed embodiment, the method further includes confirmingapplication of the full bias of the open-ended necrosis clip isoperative to cause necrosis of the left atrial appendage using at leastone of visualization and a transesophageal echocardiogram. In anothermore detailed embodiment, the method further includes disengaging theopen-ended necrosis clip from the end effector, wherein disengaging theopen-ended necrosis clip from the end effector includes disengaging atleast one wire operatively coupled to end effector and the open-endednecrosis clip. In yet another more detailed embodiment, the insertingstep includes inserting the open-ended necrosis clip and the endeffector through the trocar, and the trocar comprises a twelvemillimeter or less diameter orifice.

It is a seventh aspect of the present invention to provide a necrosisclip and applier comprising: (a) an open-ended necrosis clip comprisinga first beam longitudinally aligned with and spaced apart from a secondbeam, the first beam operatively coupled to and longitudinally alignedwith a third beam, the second beam operatively coupled to andlongitudinally aligned with a fourth beam, where the third and fourthbeams are coupled to one another, and where the first and second beamseach include an unattached terminal end; (b) an end effector including afirst jaw and a second jaw repositionably mounted to a housing, wherethe first and second jaws are detachably mounted to the open-endednecrosis clip, the end effector also including a mechanical includingcomponent parts that are configured to allow rotational and angularrepositioning with respect to a longitudinal axis extending through themechanical joint.

In a more detailed embodiment of the seventh aspect, the mechanicaljoint includes a ball and socket joint. In yet another more detailedembodiment, the end effector includes at least one of a cavity and aprojection configured to be engaged by a robotic grasper. In a furtherdetailed embodiment, the first and second jaws are operatively coupledto at least a gun tackle pulley configuration utilized to reposition atleast one of the first and second jaws with respect to one another,wherein the end effector further includes a line in communication withat least the gun tackle pulley configuration, and wherein the lineextends beyond the bounds of the end effector. In still a furtherdetailed embodiment, the apparatus further includes a first connector inoperative engagement with at least one of the open-ended necrosis clipand the end effector. In a more detailed embodiment, the first connectorincludes a first detachment line in operative engagement with the firstjaw of the end effector and the open-ended necrosis clip, and the firstconnector includes a second detachment line in operative engagement withthe second jaw of the end effector and the open-ended necrosis clip. Ina more detailed embodiment, the first jaw and the second jaw eachinclude a channel configured to receive at least one of the firstdetachment line and the second detachment line. In another more detailedembodiment, the first detachment line extends through a first loopcoupled to the first jaw when the open-ended necrosis clip is detachablymounted to the first jaw, the second detachment line extends through asecond loop coupled to the second jaw when the open-ended necrosis clipis detachably mounted to the second jaw, the first detachment line doesnot extend through the first loop coupled to the first jaw when theopen-ended necrosis clip is detached from to the first jaw, and thesecond detachment line does not extend through the second loop coupledto the second jaw when the open-ended necrosis clip is detached from tothe second jaw. In yet another more detailed embodiment, the first jawincludes a first channel configured to receive the first detachmentline, the first jaw includes a first orifice configured to receive thefirst loop, the second jaw includes a second channel configured toreceive the second detachment line, and the second jaw includes a secondorifice configured to receive the second loop. In still another moredetailed embodiment, at least the gun tackle pulley configurationincludes a first pulley, a second pulley, and a third pulley, the firstjaw is mounted to the first pulley and the third pulley, the second jawis mounted to the second pulley, and the line is fixedly coupled to thesecond jaw and repositionably engages the first pulley, the secondpulley, and the third pulley.

In yet another more detailed embodiment of the seventh aspect, at leastthe gun tackle pulley configuration includes a first pulley, a secondpulley, a third pulley, and a fourth pulley, the first jaw is mounted tothe first pulley and the third pulley, the second jaw is mounted to thesecond pulley and the fourth pulley, and the line is fixedly coupled tothe first jaw and repositionably engages the first pulley, the secondpulley, the third pulley, and the fourth pulley. In yet another moredetailed embodiment, first jaw pivotally engages the second jaw. In afurther detailed embodiment, the end effector includes a pair ofprojections configured to be grasped by a robotic fenestrated grasper.

It is an eighth aspect of the present invention to provide a medicalinstrument comprising: (a) a pair of repositionable jaws; (b) anocclusion clip detachably mounted to the pair of repositionable jaws;(c) a folding support concurrently mounted to the pair of repositionablejaws, the folding support repositionable between a folded position andan unfolded position, where the folded position has the pair ofrepositionable jaws in closer proximity to one another than in theunfolded position, and a first connection operatively coupled to thefolding support and configured to be repositioned by an instrumentotherwise untethered from the folding support, the first connectionrepositionable with respect to the folding support to facilitaterepositioning of the folding support between the folded position and theunfolded position.

In a more detailed embodiment of the eighth aspect, the apparatusfurther comprises a second connection operatively coupled to theocclusion clip and at least one of the pair of repositionable jaws whenthe occlusion clip is mounted to the pair of repositionable jaws, thesecond connection being configured to be repositioned and discontinueoperative coupling between at least one of the occlusion clip and atleast one of the pair of repositionable jaws. In yet another moredetailed embodiment, the second connection comprises a line. In afurther detailed embodiment, the line includes a first wire and a secondwire, the first wire is concurrently mounted to the occlusion clip and afirst of the pair of repositionable jaws, the second wire isconcurrently mounted to the occlusion clip and a second of the pair ofrepositionable jaws, the line is repositionable to selectively dismountthe first wire from at least one of the occlusion clip and the first ofthe pair of repositionable jaws, and is repositionable to selectivelydismount the second wire from at least one of the occlusion clip and thesecond of the pair of repositionable jaws. In still a further detailedembodiment, the line includes a first wire, the first wire isconcurrently mounted to the occlusion clip and a first of the pair ofrepositionable jaws at a first location, and concurrently mounted to theocclusion clip and a second of the pair of repositionable jaws at asecond location, the line is repositionable to selectively dismount theocclusion clip and the first of the pair of repositionable jaws, as wellas repositionable to selectively dismount the occlusion clip and thesecond of the pair of repositionable jaws. In a more detailedembodiment, the folding support is operatively coupled to a pulley andthe first link. In a more detailed embodiment, the folding supportincludes: (i) a first link concurrently repositionably and operativelycoupled to a first of the pair of repositionable jaws; (ii) a secondlink concurrently repositionably and operatively coupled to a second ofthe pair of repositionable jaws; (iii) a third link concurrentlyrepositionably and operatively coupled to the first of the pair ofrepositionable jaws and the second link; and, (iv) a fourth linkconcurrently repositionably and operatively coupled to the second of thepair of repositionable jaws and the first link, where the third link isrepositionably and operatively coupled to the fourth link. In anothermore detailed embodiment, the folding support includes a fifth linkconcurrently repositionably and operatively coupled to a sixth link andto the first link, wherein the sixth link is concurrently repositionablyand operatively coupled to the fifth link and to the second link. In yetanother more detailed embodiment, the fifth and sixth links are bothmounted to and repositionable with respect to a pulley. In still anothermore detailed embodiment, the second joint includes a first cammingsurface to facilitate repositioning of the fifth link, and the secondjoint includes a second camming surface to facilitate repositioning ofthe sixth link.

In yet another more detailed embodiment of the eighth aspect, the firstconnection is operatively coupled to the fifth and sixth links. In yetanother more detailed embodiment, the first connection includes a pulleyoperatively coupled to the fifth and sixth links. In a further detailedembodiment, the folding support comprises a folding pantograph support.

It is a ninth aspect of the present invention to provide a method ofdeploying an occlusion clip comprising: (a) inserting an occlusion clipremovably mounted to an end effector deployment device havingrepositionable jaws through at least one of an incision and a trocar,the occlusion clip and the end effector deployment device mounted to oneanother when inserted into and through at least one of the incision andthe trocar, the end effector deployment device including a foldingsupport concurrently mounted to the pair of repositionable jaws, the endeffector deployment device also including at least one of a projectionand a cavity configured to be engaged by a first surgical otherwiseuntethered to the end effector deployment device; (b) repositioning theend effector proximate a left atrial appendage by using a secondsurgical device; (c) repositioning the folding support by using a secondsurgical device, which is otherwise untethered from the end effectordeployment device, to reposition the occlusion clip so the occlusionclip is interposed by a part of a left atrial appendage in between abase and a tip of the left atrial appendage by passing the tip of theleft atrial appendage between opposing clamping surfaces of theocclusion clip; (d) repositioning the folding support by using thesecond surgical device in order for the occlusion clip to clamp the leftatrial appendage and occlude a portion of the left atrial appendagewithout piercing the left atrial appendage; (e) disengaging theocclusion clip from the end effector deployment device; and, (f)withdrawing the end effector deployment device through at least one ofthe incision and the trocar.

In a more detailed embodiment of the ninth aspect, the inserting stepoccurs during at least one of an open sternotomy, a left thoracotomy, aright thoracotomy, a left port procedure, a right port procedure, asubxiphoid approach, and a transdiaphragmatic approach. In yet anothermore detailed embodiment, the method further includes insufflating athoracic space prior to the inserting step. In a further detailedembodiment, the method further includes making an incision as part of aprocedure comprising at least one of an open sternotomy, a leftthoracotomy, a right thoracotomy, a left port procedure, a right portprocedure, a subxiphoid approach, and a transdiaphragmatic approach, andintroducing a trocar through the incision. In still a further detailedembodiment, the method further includes grasping the left atrialappendage concurrent with repositioning the end effector deploymentdevice to reposition the occlusion clip so the occlusion clip isinterposed by the portion of the left atrial appendage. In a moredetailed embodiment, the method further includes repeating therepositioning and clamping steps prior to the disengaging step. In amore detailed embodiment, the method further comprising confirming aclamping position of the occlusion clip is operative to occlude theportion of the left atrial appendage using at least one of visualizationand a transesophageal echocardiogram. In another more detailedembodiment, the inserting step includes inserting the occlusion clip andthe end effector deployment device through the trocar, the withdrawingstep includes withdrawing the end effector deployment device through thetrocar, and the trocar comprises a twelve millimeter or less diameterorifice

It is a tenth aspect of the present invention to provide a method ofdeploying an occlusion clip comprising: (a) inserting an occlusion clipremovably mounted to an end effector deployment device havingrepositionable jaws through at least one of an incision and a trocar,the occlusion clip and the end effector deployment device mounted to oneanother when inserted into and through at least one of the incision andthe trocar, the end effector deployment device including a foldingsupport concurrently mounted to the pair of repositionable jaws; (b)repositioning the end effector deployment device to reposition theocclusion clip so the occlusion clip is interposed by a portion of aleft atrial appendage interposing a base and a tip of the left atrialappendage by passing the tip of the left atrial appendage betweenopposing clamping surfaces of the occlusion clip; (c) clamping the leftatrial appendage with the occlusion clip in an initial position withoutpiercing the left atrial appendage between the occlusion clip; (d)assessing the operability of the occlusion clip in the initial positionto occlude the left atrial appendage; and, (e) repositioning the endeffector deployment device to reposition the occlusion clip to asubsequent position, different from the initial position, to clamp theleft atrial appendage, where repositioning the occlusion clip from theinitial position to the subsequent position is repeatable withoutaffecting the structural integrity of the left atrial appendage.

It is an eleventh aspect of the present invention to provide a method ofdeploying an occlusion clip comprising: (a) inserting an occlusion clipremovably mounted to an end effector deployment device, includingrepositionable jaws and a folding support concurrently mounted to therepositionable jaws, through at least one of an incision and a trocar,the occlusion clip biased to a clamping position; (b) repositioning theend effector deployment device to counteract a bias of the occlusionclip and reposition the occlusion clip to a tissue insertion positionwhere the full bias of the occlusion clip is not applied to a leftatrial appendage tissue; (c) repositioning the end effector deploymentdevice to reposition the occlusion clip in the tissue insertion positionso a portion of a left atrial appendage between a base and a tip of theleft atrial appendage interposes the occlusion clip by having the tip ofthe left atrial appendage pass between opposing beams of the occlusionclip; (d) repositioning the occlusion clip to apply the full bias to theleft atrial appendage; and (e) removing the end effector deploymentdevice from around the left atrial appendage without passing the tip ofthe left atrial appendage between the repositionable jaws.

In a more detailed embodiment of the eleventh aspect, the method furtherincludes disengaging the occlusion clip from the end effector deploymentdevice, and withdrawing the end effector deployment device through atleast one of the incision and the trocar. In yet another more detailedembodiment, the inserting step occurs during at least one of an opensternotomy, a left thoracotomy, a right thoracotomy, a left portprocedure, a right port procedure, a subxiphoid approach, and atransdiaphragmatic approach. In a further detailed embodiment, themethod further includes insufflating a thoracic space prior to theinserting step. In still a further detailed embodiment, the methodfurther includes making an incision as part of a procedure comprising atleast one of an open sternotomy, a left thoracotomy, a rightthoracotomy, a left port procedure, a right port procedure, a subxiphoidapproach, and a transdiaphragmatic approach, and introducing a trocarthrough the incision. In a more detailed embodiment, the method furtherincludes grasping the left atrial appendage concurrent withrepositioning the end effector deployment device to reposition theocclusion clip so the open end of the occlusion clip is interposed bythe portion of the left atrial appendage. In a more detailed embodiment,the method further includes confirming application of the full bias ofthe occlusion clip is operative to occlude the left atrial appendageusing at least one of visualization and a transesophagealechocardiogram. In another more detailed embodiment, the inserting stepincludes inserting the occlusion clip and the end effector deploymentdevice through the trocar, and the trocar comprises a twelve millimeteror less diameter orifice. In yet another more detailed embodiment, therepositionable jaws include a pair of jaws that at least one of parallelopen and parallel close, the pair of jaws comprise a first jaw and asecond jaw, the first jaw is pivotally mounted to a first drive link anda first parallel link, the second jaw is pivotally mounted to a seconddrive link and a second parallel link, at least two of the first drivelink, the second drive link, the first parallel link, and the secondparallel link are pivotally mounted to a pulley.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is an elevated perspective view of a first exemplary end effectorcoupled to a clip in a closed position in accordance with the instantdisclosure shown coupled to first and second robotic graspers.

FIG. 2 is an elevated perspective view of the first exemplary endeffector of FIG. 1, while coupled to a clip, shown with the clip in anopen position in accordance with the instant disclosure when coupled tofirst and second robotic graspers.

FIG. 3 is an exploded view of the first exemplary end effector of FIG. 1with the occlusion clip.

FIG. 4 is a top view of an exemplary housing comprising part of thefirst exemplary end effector of FIG. 1.

FIG. 5 is a profile view of the exemplary housing of FIG. 4.

FIG. 6 is a proximal end view of the exemplary housing of FIG. 4.

FIG. 7 is a cross-sectional view of the exemplary housing of FIG. 4taken along line 4-4.

FIG. 8 is a cross-sectional view of portions of the exemplary endeffector of FIG. 9 taken along line 9-9.

FIG. 9 is an elevated perspective view of portions of the exemplary endeffector in a closed position.

FIG. 10 is an elevated perspective view from an interior, proximal endof a first jaw in accordance with the instant invention.

FIG. 11 is an exterior side view of the first jaw of FIG. 10.

FIG. 12 is a bottom view of a second jaw in accordance with the instantdisclosure.

FIG. 13 is an elevated perspective view from an interior, proximal endof the second jaw of FIG. 12.

FIG. 14 is an elevated perspective view from a proximal end, taken of aportion of the first exemplary end effector without the exemplaryhousing to show orientation and positioning of deployment wires andcontrol wires for the exemplary jaws in accordance with the instantdisclosure.

FIG. 15 is an elevated perspective view of the end effector of FIG. 1shown partially mounted to an occlusion clip via one jaw, while thesecond jaw is not shown to depict the position of the suture loops withrespect to the clip when otherwise mounted to the dual jaws when thejaws are in an open position.

FIG. 16 is a profile view of a first alternate exemplary embodiment ofan end effector for deploying an occlusion clip.

FIG. 17 is an elevated perspective view of a second exemplary endeffector for deploying a clip in accordance with the instant disclosureshown mounted to first and second robotic tools with the clip in an openposition.

FIG. 18 is an elevated perspective view of the end effector of FIG. 1,with the clip in a closed position.

FIG. 19 is an exploded view of the end effector of FIGS. 1 and 2 withthe occlusion clip.

FIG. 20 is an elevated perspective view from a proximal end of anexemplary linkage housing in accordance with the instant disclosure.

FIG. 21 is an elevated perspective view from a distal end of theexemplary linkage housing of FIG. 20.

FIG. 22 is a cross-sectional view of the exemplary linkage housing ofFIG. 21 taken along line 21-21.

FIG. 23 is an elevated perspective view from a proximal end of anexemplary drive link in accordance with the instant disclosure.

FIG. 24 is an elevated perspective view from a distal end of theexemplary drive link of FIG. 23.

FIG. 25 is a profile view of the exemplary drive link of FIG. 23.

FIG. 26 is an elevated perspective view from a distal end of a first jawin accordance with the instant invention.

FIG. 27 is profile view of a second jaw in accordance with the instantinvention.

FIG. 28 is an elevated perspective view from a proximal end of anexemplary parallel link in accordance with the instant disclosure.

FIG. 29 is an elevated perspective view from a side of the exemplaryparallel link of FIG. 28.

FIG. 30 is a bottom view of the exemplary parallel link of FIG. 28.

FIG. 31 is an elevated perspective view from a side showing theexemplary parallel links aligned with one another in a compact position.

FIG. 32 is an elevated perspective view from a distal end of anexemplary toggle in accordance with the instant disclosure.

FIG. 33 is an elevated perspective view from a bottom of the exemplarytoggle of FIG. 32.

FIG. 34 is a profile view of the exemplary toggle of FIG. 32.

FIG. 35 is an elevated perspective view showing assembly of the togglesand drive links.

FIG. 36 is an elevated perspective view showing assembly of the toggles,parallel links, and drive links.

FIG. 37 is an elevated perspective view of an exemplary end effectorhaving mounted thereto an occlusion clip in a closed position.

FIG. 38 is an elevated perspective view of the exemplary end effectorand occlusion clip of FIG. 37 shown without repositionable jaws.

FIG. 39 is an elevated perspective view of the exemplary end effectorand occlusion clip of FIG. 37 shown without repositionable jaws, firstand second drive links, and first and second parallel links.

FIG. 40 is an elevated perspective view of the exemplary end effectorand occlusion clip of FIG. 37 shown without repositionable jaws, firstand second drive links, first and second parallel links, and first andsecond toggles.

DETAILED DESCRIPTION

The exemplary embodiments of the present disclosure are described andillustrated below to encompass devices, methods, and techniques relatingto surgical procedures. Of course, it will be apparent to those ofordinary skill in the art that the embodiments discussed below areexemplary in nature and may be reconfigured without departing from thescope and spirit of the present disclosure. It is also to be understoodthat variations of the exemplary embodiments contemplated by one ofordinary skill in the art shall concurrently comprise part of theinstant disclosure. However, for clarity and precision, the exemplaryembodiments as discussed below may include optional steps, methods, andfeatures that one of ordinary skill should recognize as not being arequisite to fall within the scope of the present disclosure.

Referencing FIGS. 1-3, a first exemplary robotic end effector 100 may beused in minimally invasive surgical procedures to allow deployment of anLAA occlusion clip 102 with respect to a left atrial appendage (notshown) with the assistance of a surgical position, such as a robotic armhaving a robotic grasper 104 provided as part of the da Vinci surgicalsystem available from Intuitive Surgical. U.S. Provisional PatentApplication No. 62/091,230, and U.S. Nonprovisisonal patent applicationSer. No. 14/964,930, which each describe an exemplary LAAocclusion/necrosis clip 102, are incorporated herein by reference. Aswill be apparent to those skilled in the art after reviewing the instantdisclosure, the end effector 100 may be utilized in capacities otherthan LAA occlusion clip deployment, each of which is within the scope ofthis disclosure.

The end effector 100 comprises a housing 130 that is mounted distally toa first pin 140 and a second pin 150 that extend through correspondingdistal openings 662 of a first jaw 160 and a second jaw 170 (see FIG.10). In this fashion, the jaws 160, 170 are rotatably repositionablewith respect to the housing 130 and with respect to one another. Eachjaw 160, 170 includes a set of U-shaped proximal projections thatoverlap one another and each include a through opening 682 aligned withone another configured to receive a respective third pin 180 and fourthpin 190 (see FIG. 10). The spacing between the U-shaped projections issufficient to each accommodate a respective pair of pulleys 200, 210that rotate about a respective pin 180, 190. As will be discussed inmore detail hereafter, a control wire 1364 is fed around the pulleys200, 210 and is utilized to cause the jaws 160, 170 to pivot withrespect to one another and with respect to the housing 130 for openingand closing in a non-parallel fashion. More specifically, when a firstfenestrated robotic grasper 80 sandwiches the housing 130, and a secondfenestrated robotic grasper 90 captures an enlarged portion 1365 of thecontrol wire 1364, continued tensioning of the control wire resultingfrom movement of the second fenestrated robotic grasper away from thehousing 130 causes the first and second jaws 160, 170 to pivot withrespect to one another and cause the occlusion/necrosis clip 102 mountedthereto to progressively open. FIG. 1 depicts the occlusion/necrosisclip 102 in a closed position, while FIG. 2 depicts theocclusion/necrosis clip 102 in an open position. A more detaileddiscussion of the component parts of the end effector 100 follows.

As shown in FIGS. 4-7, the housing 130 includes an outer shell 400 thatdefines a longitudinal passage 402 extending therethrough. Thelongitudinal passage 402 is sized to accommodate the control wire 1364coupled to the pulleys 200, 210 (see FIG. 3) in addition to a pair ofdeployment wires 1402, 1404 (see FIG. 14) used to selectively couple theocclusion clip 102 to the respective jaws 160, 170. As will be discussedin more detail hereafter, repositioning of the control wire 1364 withrespect to the housing 130 and pulleys 200, 210 results in componentmotion operative to increase or decrease the distance between the distalends of the opposing jaws 160, 170 (when the occlusion clip 102 ismounted to the jaws 160, 170, this component motion is also operative toopen or close the occlusion clip).

The outer shell 400 also includes a ledge 420 on its proximal end fromwhich extend opposing projections 422. The projections 422 are sized toallow grasping by the first fenestrated robotic grasper 80, such as arobotic grasper provided as part of the da Vinci surgical systemavailable from Intuitive Surgical. As will be discussed in more detailhereafter, first fenestrated robotic grasper 80 is intended to directrepositioning of the end effector 100 independent of the position of thesecond fenestrated robotic grasper 90. Opposite the proximal end, theouter shell 400 is configured to be repositionably mounted to the jaws160, 170 on its distal end.

In exemplary form, a distal end of the housing 130 includes a pair ofouter retention arms 530, 532 each including facing interior planarsurfaces 554, that are bridged laterally by complementary arcuatesurfaces 558 and opposing exterior surfaces 556. A distal most portionof each retention arm 530, 532 includes a planar surface 560 normal tothe interior and exterior surfaces 554, 556. In this exemplaryembodiment, the retention arms 530, 532 have a rounded, rectangularfootprint typified by the interior surfaces 554 having a roundedrectangular footprint slightly larger than the exterior surfaces 556rounded rectangular footprint. Proximate the distal, ninety degreecorners of the retention arms 530, 532 are corresponding through holes564 that extend between the interior and exterior surfaces 554, 556.

Each through hole 564 is sized to receive at least one of the first pin140 and the second pin 150 in order to pivotally mount a correspondingjaw 160, 170 to the housing 130 (see FIG. 3). In this exemplaryembodiment, each through hole 564 is sized to retain a corresponding pin140, 150 therein via a friction fit (though fits other than a frictionfit may be utilized) so that the pin does not rotate with respect to thehousing 130, but nonetheless the jaws 160, 170 are able to rotate aboutthe pins 140, 50. It should be noted that alternatively, for example,the through holes 564 may be sized to allow rotation of a correspondingpin 140, 150 therein so that the pins and jaws 160, 170 rotate togetherwith respect to the housing 130 (in which case the pin 140, 150 receivedby a respective jaw 160, 170 may not be independently rotationallyrepositionable with respect to that jaw).

Referencing FIGS. 8-14, the jaws 160, 170 are structurally mirror imagesof one another, with the exception of the cams 600, 602. Consequently,the following discussion of the structure of a jaw is generallyapplicable to both the first and second jaws 160, 170 unless otherwisenoted.

Each jaw 160, 170 includes a rounded proximal end 660 that transitionsdistally into a rectangular cross-section with an openings 662,extending between opposing top and bottom surfaces 666, 668, and havinga cylindrical shape configured to receive one of the first and secondpins 140, 150. In this fashion, the first and second jaws 160, 170 maybe rotationally repositionable with respect to the housing 130 bypivoting about the first and second pins 140, 150. A corresponding cam600, 602 extends from an interior surface 670 spanning between the topand bottom surfaces 666, 668. The cams 600, 602 engage one another toguide pivoting of the jaws 160, 170 with respect to one another. Inexemplary form, the first cam 600 of the first jaw 160 has a roundedrectangular profile but for a U-shaped cavity 674 formed therein, withspaced apart ends 672 that are rounded. This U-shaped cavity 674 isconfigured to receive a corresponding rounded projection 676 of thesecond cam 602. Moreover, rounded shoulders 678 of the second cam 602are configured to engage the rounded ends 672 of the first cam 600 inorder to provide corresponding range of motion stops. In particular, thedistal most rounded end 672 of the first cam 600 will engage the distalmost rounded shoulder 678 of the second cam 602 to limit the pivotalmotion of the jaws 160, 170 toward one another. Similarly, the proximalmost rounded end 672 of the first cam 600 will engage the proximal mostrounded shoulder 678 of the second cam 602 to limit the pivotal motionof the jaws 160, 170 away from one another. In other words, the roundedends 672 of the first cam 600 do not engage the rounded shoulders 678 ofthe second cam 602 until an end of the range of motion of the jaws 160,170 is reached. Conversely, the surface of the first cam 600 delineatingthe U-shaped cavity 674 is configured to maintain contact with thesurface delineating the rounded projection 676 of the second cam 602through the pivotal range of motion of the jaws 160, 170 with respect toone another.

As part of repositioning the jaws 160, 170 with respect to one another,the proximal end 660 of each jaw includes a cavity 680 that is sized toreceive a corresponding pair of pulleys 200, 210. In order to mount thepulleys 200, 210 to the jaws 160, 170, a pair of through openings 682extends through portions of the jaws, where the through openings 682 arelongitudinally aligned. More specifically, the through openings 682 areconfigured to receive a corresponding third or fourth pin 180, 190 thatconcurrently extends through the corresponding pulleys 200, 210 in orderto mount the pulleys to a jaw. In this exemplary embodiment, eachthrough opening 682 is sized to retain a corresponding pin 180, 190therein via a friction fit so that the pin does not rotate or movelongitudinally with respect to the jaw 160, 170, though fits other thana friction fit may be utilized, while allowing the pulleys 200, 210 torotate with respect to the pin and jaw. Unlike the second jaw 170, thefirst jaw 160 includes a through opening 684 extending between theinterior surface 670 and an exterior surface 671 of therectangular-shape profile section. This through opening 684 is sized toreceive an end of the control wire 1364 and allow the control wire topass therethrough, but not so large as to allow an enlarged end of thecontrol wire to pass therethrough. Accordingly, as the control wire 1364is tensioned, the structure delineating the through opening 684 acts asan anchor to hold an end of the control wire in place. Thus, the pulleys200, 210 are positioned in a double tackle configuration. As usedherein, “tackle” refers to a rope, wire, or other connector sectionthreaded between two blocks, where “block” refers to a pulley mounted ona single axle. As known by those skilled in the art, tackles may beduplicated to create greater and greater mechanical advantage. By way ofexample, a double tackle configuration comprises four rope sections ofthe tackles, whereas a luff tackle comprises three rope sections, and agun tackle comprises two rope sections. In this manner, a luff tackleand a double tackle inherently include a gun tackle. Wires can be singlestrand metal wire (stainless, music wire, copper, aluminum) or a thinplastic rod made from monofilament flexible plastics such as UHMW,nylon, Teflon, urethane, PET etc., or braided ropes such as metallic(e.g., stainless steel, nitinol, etc.), plastic, and composite.

Though the foregoing exemplary embodiment has been described using fourpulleys 200, 210 in a double tackle configuration, it should be notedthat other pulley configurations may be used, such as, withoutlimitation, a gun tackle configuration, a watch/Luff tackleconfiguration, a Gyn tackle configuration, and a three fold purchaseconfiguration, as well as combinations and duplications of theforegoing.

Extending distally past the rectangular cross-section, each jaw 160, 170includes an arcuate profile that is slightly convex on an exteriorsurface 692 and concave on an interior surface 690. Opposing top andbottom surfaces 696, 698 are essentially planar and extend parallel toone another. Perimeter surfaces 694 extending between the interiorsurface 690 and corresponding top and bottom surfaces 696, 698 have anarcuate shape in the longitudinal direction (proximal to distal) andthese surfaces cooperate to delineate an interior recess 700 that issized to receive a corresponding portion of the occlusion clip 102. Onthe opposite exterior surface 692, a channel 702 is sized and configuredto receive a respective deployment wire 1402, 1404 (see FIG. 14),whereas the openings 686 are sized to accommodate throughput of a sutureretainer coupled to the occlusion clip 102.

Referring to FIGS. 1-3 and 14, an exemplary assembly sequence for theexemplary end effector 100 will now be described. Initially, the controland deployment wires 1364, 1402, 1404 are routed through the housing130. Specifically, the wires 1364, 1402, 1404 extend through thelongitudinal passage 402 of the housing 130. It should be noted that forsimplicity, the deployment wires 1402, 1404 have been omitted from FIGS.1-3 to show operation of the deployment wire 1364 to open and close thejaws 160, 170.

Each jaw 160, 170 is prepared for mounting to the housing 130 bymounting each jaw to a respective set of pulleys 200, 210. Specifically,the first set of pulleys 200 are inserted into the proximal end cavity680 so that the openings through the pulleys are aligned withcorresponding openings 682 of the first jaw 160. Thereafter, the thirdpin 180 is inserted into the openings 682 and through the pulleys 200 inorder to mount the pulleys to the first jaw 160. Similarly, the secondset of pulleys 210 are inserted into the proximal end cavity 680 of thesecond jaw 170 so that the openings through the pulleys are aligned withcorresponding openings 682 of the second jaw. Thereafter, the fourth pin190 is inserted into the openings 682 and through the pulleys 210 inorder to mount the pulleys to the second jaw 170. After the pulleys 200,210 are mounted to a respective jaw 160, 170, the control wire 1364 isthreaded around the pulleys 200, 210 so that a distal enlarged endextends through the opening 684 of the first jaw 160. The control wire1364 may then be processed (such as by attaching a spherical retainer)to enlarge the distal end prohibiting throughput of an end portion ofthe control wire through the opening 684. Likewise, the deployment wires1402, 1404 are directed into corresponding channels 702 (see FIG. 11) ofthe jaws 160, 170.

Referring to FIGS. 1-3 and 7-15, post preparation, each jaw 160, 170 ismounted to the housing 130. In exemplary form, the interiors of each jaw160, 170 are oriented to face one another and the openings 662 of eachjaw are aligned with a respective through hole 564 of the housing 130.Thereafter, first and second pins 140, 150 are inserted through theholes 564 and through the openings 662 so that the jaws 160, 170 arepivotally mounted to the housing 130. The size of the pins 140, 150 issuch that the pins are press fit in the jaws and slip fit with respectto the housing 130, but are not large enough in diameter to inhibitrotation of the jaws 160, 170 when the control wire 1364 is repositionedwith respect to the pulleys 200, 210. In this alignment, the cams 600,602 engage one another to guide rotational repositioning of the jaws160, 170 with respect to one another. More specifically, the U-shapedcavity 674 of the first cam 600 receives the rounded projection 676 ofthe second cam 602.

After the jaws 160, 170 have been mounted to the housing 130, theocclusion clip 102 may be mounted to the jaws. In exemplary form, theocclusion clip 102 is oriented so that its parallel beams arelongitudinally aligned and inset with respect to the jaws 160, 170, andso that the open end of the occlusion clip is adjacent the open end ofthe jaws. A series of suture loops 725 (e.g., retainer loops) arelongitudinally spaced apart and extend along a length of each beam ofthe occlusion clip 102, where a portion of each retainer extends througha corresponding opening 686 of an adjacent jaw 160, 170 so that a sutureloop 725 extends through each opening 686 and exits on an exterior of arespective jaw. Thereafter, a respective deployment wire 1402, 1404 isfed into a respective channel 702 so that the deployment wire extendsthrough each of the suture loops 725. In this fashion, the occlusionclip 102 is inhibited from detaching from the jaws 160, 170 until thedeployment wires 1402, 1404 are withdrawn from the retainer loops, thusallowing the loops to be pulled through the openings 686 to free theocclusion clip from the jaws. And the deployment wires 1402, 1404 alongwith the control wire 1364 are manipulated via the user control 20.

The following is an exemplary procedure for utilizing the exemplary endeffector 100 to deploy the occlusion clip 102 to occlude a left atrialappendage (LAA). Initially, an incision is made on either the left orright side of the chest wall in an intercostal space that is appropriatefor the desired angle of approach to a LAA. The incision may be madethrough the chest wall or through the abdomen (or through the back) aspart of various procedures that include, without limitation, an opensternotomy, a left thoracotomy, a right thoracotomy, a left port, aright port, a subxiphoid approach, and a transdiaphragmatic approach.Post incision, a trocar (e.g., 12 millimeter or smaller) may be insertedthrough the incision to extend into the thoracic cavity. In certaininstances, it may be preferred to insufflate the thoracic spacesubsequent to trocar insertion using known techniques. Using at leastone of the incision and trocar, surgical instruments are introduced intothe thoracic space in order to perform a series of dissections,including dissection of the pericardium, to provide egress to the LAA.After having access to the LAA, the end effector 100 may be insertedinto the thoracic cavity by way of the incision or trocar.

After the end effector 100 is passed through the trocar or incision, thesurgeon may utilize a first fenestrated robotic grasper 80 to grasp theouter housing 130. In exemplary form, the first fenestrated roboticgrasper 80 may include a pair of bounded openings sized to receive theopposing projections 422 of the outer housing 130. In this fashion, oncethe robotic grasper 80 grasps the outer housing 130 so that the opposingprojections 422 are received within the bounded openings, the roboticgrasper controls repositioning of the end effector 100 (but not openingand closing of the jaws 160, 170 or clip 102 deployment from the endeffector). As a result, the user controlling the position of the roboticgrasper 80 is operative to navigate the end effector 100 (and occlusionclip 102) proximate the LAA. By way of example, the robotic grasper 80is operative to vary the yaw of the end effector 100 within an X-Yplane, as well as being operative to vary the pitch of the end effectorwithin a Y-Z plane. After navigating the LAA occlusion clip 102proximate the LAA, the occlusion clip is opened prior to deployment onthe LAA.

Opening the LAA occlusion clip 102 is carried out by using a secondfenestrated robotic grasper 90. In particular, robotic grasper 90circumscribes the enlarged end 1365 of the control wire 1364 while thejaws of the robotic grasper sandwich a portion of the control wiretherebetween. In this fashion, as the robotic grasper is repositionedaway from the proximal end of the outer housing 130, the control wire1364 is tensioned and pulled proximally. This proximal movement of thecontrol wire 1364 causes the control wire extending between the pulleys200, 210 to decrease, thereby causing the proximal ends of its jaws 160,170 to move toward one another. This movement of the proximal ends ofthe jaws 160, 170 toward one another coincides with the distal ends ofthe jaws (comprising the far end of the end effector 100) moving awayfrom one another to effectively open the jaws and correspondingly opensthe clip 102, which is suture 725 tied to the jaws at this point. Postopening of the LAA occlusion clip 102, the clip is repositioned usingthe first robotic grasper 80 is repositioned (in concert with the secondrobotic grasper 90 to maintain the control wire 1364 in tension tomaintain the open position of the jaws 160, 170) so that the open end ofthe occlusion clip is advanced from a side of the LAA, proximate thebase of the LAA, until an entire circumference of the LAA interposescorresponding occlusion surfaces of the clip. It should be noted thatforceps may be used to grasp a portion of the LAA (proximate the LAAtip) when repositioning the LAA occlusion clip 102 via the roboticgrasper 80. After the clip 102 has been positioned at the base of theLAA, with the LAA interposing corresponding occlusion surfaces of theclip, second robotic grasper 90 may be repositioned toward the outerhousing 130, which results in a greater amount of control wire betweenthe pulleys 200, 210, thus allowing the proximal ends of the jaws tomove away from one another, thereby moving the distal ends of the jawstoward one another and eventually closing the clip 102 to sandwich theLAA between the occlusion clip surfaces. It should be noted that varioussteps may be undertaken to ensure the entire periphery of a portion ofLAA is sandwiched by the clip 102 such as, without limitation, directvisual verification and utilization of a transesophageal echocardiogram.If any problems are determined with respect to clip 102 placement, theopening and closing clip sequence may be repeated along withrepositioning of the end effector 100 and clip 102 using the roboticgraspers 80, 90 to adjust the positioning of the clip with respect tothe LAA. Upon closing the occlusion clip 102 around a periphery of aportion of the LAA, proximate the LAA base, as well as confirming theplacement of the closed clip being operative to occlude the LAA, thesurgeon may release the clip from the end effector 100.

To release the clip 102 from the end effector 100, the deployment wires1402, 1404 are repositioned proximally and discontinue engagement withthe suture loops 725 that were previously concurrently attached to thedeployment clip 102 and the jaws 160, 170. When the engagement betweenthe deployment wires 1402, 1404 and the suture loops 725 isdiscontinued, the occlusion clip 102 is no longer fastened to the jaws160, 170 (i.e., the jaws can be opened and closed without repositioningthe clip). In exemplary form, after the second robotic grasper 90 isfinished with grasping the control wire 1364 to open and close the jaws160, 170, the second robotic grasper may be utilized to grasp theexposed portions of the deployment wires 1402, 1404 extending proximallyfrom the jaws. The second grasper 90 may grasp one or both deploymentwires 1402, 1404 and be pulled away from the outer housing 130 in astraight pull fashion until each wire no longer engages the suture loops725. After disengagement between the occlusion clip 102 and the endeffector 100, the end effector is may be repositioned from proximate theLAA by repositioning the first robotic grasper 80, thereby removing theend effector from the cardiac space.

Removal of the end effector 100 from the patient's body may becontrolled via any number of methods. Because the end effector 100 isopen-ended, there is no need to reposition the end effector upward alongthe LAA tip because the end effector can be withdrawn laterally, thusreducing the potential for contact between the end effector and the LAA.In other words, the end effector 100 may be removed from around the LAAwithout having a tip of the LAA passing between the jaws 160, 170.

Turning to FIG. 16, an alternate exemplary end effector 100′, which maybe utilized in lieu of the first exemplary end effector 100, comprises atwo piece housing 130′ which is slightly different from the single pieceouter housing 130 previously discussed. Unless otherwise noted, thestructures of the housings 130, 130′ are the same. The housing 130′includes an outer shell 400′ that defines a longitudinal passage 402′extending therethrough. A proximal end 404′ of the shell 400′ thatpartially delineates the longitudinal passage 402′ includes a sphericalprojection 300 that is repositionable with respect to a receiver 302,which is configured to be grasped by a first fenestrated grasper 80. Inexemplary form, the receiver 302 includes a bowl 304 that delineates asemi spherical depression into which the projection 300 is received.More specifically, the projection 300 is repositionably coupled to thereceiver 302 so that the projection is rotationally repositionable aboutan X-axis 306 that extends axially through the receiver 302. Inaddition, the projection 300 is angularly repositionable with respect tothe X-axis 304 between zero and fifty-five degrees. The longitudinalpassage 402′ is also partially delineated by the receiver 302 in orderto allow throughput and repositioning of the deployment wires 1402, 1404and control wire 1364, which are respectively mounted to the jaws 160,170 and pulleys 200, 210 (not shown in FIG. 16).

The receiver 302 includes an inner, cylindrical surface 406 thatcircumscribes a distal end 1390 (see FIG. 3) of the flexible tubing 30and retains the distal end of the flexible tubing therein via acompression fit or adhesive fit, for example. As was discussedpreviously, repositioning of the control wire 1364 may result incomponent motion operative to increase or decrease the distance betweenthe distal ends of the opposing jaws 160, 170 (when the occlusion clip102 is mounted to the jaws 160, 170, this component motion is alsooperative to open or close the occlusion clip).

As with the first exemplary housing 130, the receiver 302 of thisalternate exemplary housing 103′ includes a ledge on its proximal endfrom which extend opposing projections (not shown). The projections aresized to allow grasping by a surgical grasping and repositioning tool104, such as a robotic grasper provided as part of the da Vinci surgicalsystem available from Intuitive Surgical. As discussed previously, thesurgical grasping and repositioning tool 104 is intended to directrepositioning of the end effector independent of the position of theuser control 20 by taking into account the properties of the flexibletube 30.

As with the first exemplary housing 130, the outer shell 400′ includes apair of outer retention arms 530, 532 each including opposed exteriorand interior planar surfaces 554, 556, that are bridged laterally bycomplementary arcuate surfaces 558. A distal most portion of eachretention arm 530, 532 includes a planar surface 560 normal to theinterior and exterior planar surfaces 554, 556. In this exemplaryembodiment, the retention arms 530, 532 have a rounded, rectangularfootprint typified by the interior surfaces 556 having a roundedrectangular footprint slightly larger than the exterior surfaces 554rounded rectangular footprint. Proximate the distal, ninety degreecorners of the retention arms 530, 532 are corresponding through holes564 that extend between the interior and exterior surfaces 554, 556.

As depicted in FIG. 16, analogous to the first exemplary end effector100, each through hole 564 is sized to receive at least one of the firstpin 140 and the second pin 150 in order to pivotally mount acorresponding jaw 160, 170 to the housing 130. In this exemplaryembodiment, each through hole 564 is sized to retain a corresponding pin140, 150 therein via a friction fit (though fits other than a frictionfit may be utilized) so that the pin does not rotate with respect to thehousing 130, but nonetheless the jaws 160, 170 rotate about the pins140, 50. It should be noted that alternatively, for example, the throughholes 564 may be sized to allow rotation of a corresponding pin 140, 150therein so that the pins and jaws 160, 170 rotate together with respectto the housing 130 (in which case the pin 140, 150 received by arespective jaw 160, 170 may not be independently rotationallyrepositionable with respect to that jaw).

An exemplary assembly sequence for the alternate exemplary end effector100′ includes mounting the outer shell 400′ to the receiver 302. Morespecifically, the projection 300 of the outer shell 400′ is receivedwithin the bowl 304 to create a snap-fit connection as a result of thebowl circumscribing more than 180 degrees of the spherical projection.Yet in this snap-fit connection, the projection 300 is repositionablycoupled to the receiver 302 so that the projection is rotationallyrepositionable about the X-axis 304 and angularly repositionable withrespect to the X-axis 304 between zero and fifty-five degrees. Postmounting the outer shell 400′ to the receiver 302, the control anddeployment wires 1364, 1402, 1404 may be routed through the housing 130′along the longitudinal passage 402′ and through the flexible tube 30.Specifically, the wires 1364, 1402, 1404 extend through the longitudinalpassage 402′ of the housing 130′, through the hollow flexible tube 30,and into the interior of the user control 20.

Each jaw 160, 170 is prepared for mounting to the outer shell 400′ ofthe housing 130′ by mounting each jaw to a respective set of pulleys200, 210. Specifically, the first set of pulleys 200 are inserted intothe proximal end cavity 680 so that the openings through the pulleys arealigned with corresponding openings 682 of the first jaw 160.Thereafter, the third pin 180 is inserted into the openings 682 andthrough the pulleys 200 in order to mount the pulleys to the first jaw160. Similarly, the second set of pulleys 210 are inserted into theproximal end cavity 680 of the second jaw 170 so that the openingsthrough the pulleys are aligned with corresponding openings 682 of thesecond jaw. Thereafter, the fourth pin 190 is inserted into the openings682 and through the pulleys 210 in order to mount the pulleys to thesecond jaw 170. After the pulleys 200, 210 are mounted to a respectivejaw 160, 170, the control wire 1364 is threaded around the pulleys 200,210 so that a distal end extends through the opening 684 of the firstjaw 160. The control wire 1364 may then be processed (such as byattaching a spherical retainer) to enlarge the distal end prohibitingthroughput of an end portion of the control wire through the opening684. Likewise, the deployment wires 1402, 1404 are directed intocorresponding channels 702 of the jaws 160, 170.

Post preparation, each jaw 160, 170 is mounted to the outer shell 400′of the housing 130′. In exemplary form, the interiors of each jaw 160,170 are oriented to face one another and the openings 662 of each jaware aligned with a respective through hole 564 of the outer shell 400′.Thereafter, first and second pins 140, 150 are inserted through theholes 564 and through the openings 662 so that the jaws 160, 170 arepivotally mounted to the outer shell 400′. The size of the pins 140, 150is such that the pins frictionally fit with respect to the outer shell400′, but are not large enough in diameter to inhibit rotation of thejaws 160, 170 when the control wire 1364 is repositioned with respect tothe pulleys 200, 210. In this alignment, the cams 600, 602 engage oneanother to guide rotational repositioning of the jaws 160, 170 withrespect to one another. More specifically, the U-shaped cavity 674 ofthe first cam 600 receives the rounded projection 676 of the second cam602.

After the jaws 160, 170 have been mounted to the outer shell 400′, theocclusion clip 102 may be mounted to the jaws. In exemplary form, theocclusion clip 102 is oriented so that its parallel beams arelongitudinally aligned and inset with respect to the jaws 160, 170, andso that the open end of the occlusion clip is adjacent the open end ofthe jaws. A series of suture loops 725 (e.g., retainer loops) arelongitudinally spaced apart and extend along a length of each beam ofthe occlusion clip 102, where a portion of each retainer extends througha corresponding opening 686 of an adjacent jaw 160, 170 so that a sutureloop 725 extends through each opening 686 and exits on an exterior of arespective jaw. Thereafter, a respective deployment wires 1402, 1404 isfed into a respective channel 702 so that the deployment wire extendsthrough each of the suture loops 725. In this fashion, the occlusionclip 102 is inhibited from detaching from the jaws 160, 170 until thedeployment wires 1402, 1404 are withdrawn from the retainer loops, thusallowing the loops to be pulled through the openings 686 to free theocclusion clip from the jaws. And the deployment wires 1402, 1404 alongwith the control wire 1364 are manipulated via the user control 20.

Consistent with the foregoing exemplary discussion for utilizing thefirst exemplary end effector 100, the second exemplary end effector 100′may be similarly utilized in lieu of the first exemplary end effector100 and, consequently, a detailed explanation of utilizing the secondexemplary end effector 100 has been omitted in furtherance of brevity.

Referring to FIGS. 17-40, an exemplary end effector 2100 may be used inminimally invasive surgical procedures to allow deployment of an LAAocclusion clip 2102 with respect to a left atrial appendage (not shown).United States Patent Application Publication number 2012/0059400, whichdescribes an exemplary LAA occlusion clip 2102, is incorporated hereinby reference. As will be apparent to those skilled in the art afterreviewing the instant disclosure, the end effector 2100 may be utilizedin capacities other than LAA occlusion clip deployment, each of which iswithin the scope of this disclosure.

The end effector 2100 comprises a linkage housing 2130, where a medialportion of the linkage housing 2130 has mounted to it a first pin 2160that extends through a first drive link 2140 and a second drive link2150. In this fashion, the first drive link 2140 and the second drivelink 2150 are rotatably repositionable with respect to the linkagehousing 2130 and with respect to one another along a common axislongitudinally aligned with the first pin 2160. A distal portion of thelinkage housing 2130 has mounted to it a second pin 2170 and a third pin2230 that extends through proximal ends of a first parallel link 2180and a second parallel link 2190. In this fashion, the first parallellink 2180 and the second parallel link 2190 are rotatably repositionablewith respect to the linkage housing 2130 and with respect to one anotheralong a common axis longitudinally aligned with the second and thirdpins 2170, 2230.

Interposing the proximal ends of the first and second parallel links2180, 2190 are a first toggle 2200, a second toggle 2210, and a pulley2220. The pulley 2220 includes a pair of cylindrical projectionsextending in opposite directions along a rotational axis of the pulley,where the first toggle 2200 is mounted to a first of the cylindricalprojections and the second toggle 2210 is mounted to a second of thecylindrical projections. A distal end of the first drive link 2140 ismounted to a proximal end of a first jaw 2240, whereas a distal end ofthe second drive link 2150 is mounted to a proximal end of a second jaw2250. In this fashion, the first drive link 2140 is rotatablyrepositionable with respect to the first jaw 2240 along a common axislongitudinally aligned with a fifth pin 2260 that concurrently extendsthrough the first drive link and the first jaw. Similarly, the seconddrive link 2150 is rotatably repositionable with respect to the secondjaw 2250 along a common axis longitudinally aligned with a sixth pin2270 that concurrently extends through the second drive link and thesecond jaw.

Near the proximal end of the first jaw 2240, inset distally from thelocation where the first drive link 2140 is mounted, the distal end ofthe first parallel link 2180 is mounted to the first jaw. In thisfashion, the first parallel link 2180 is rotatably repositionable withrespect to the first jaw 2240 along a common axis longitudinally alignedwith a seventh pin 2290 that concurrently extends through the firstparallel link and the first jaw. In corresponding fashion, the proximalend of the second jaw 2250, inset distally from the location where thesecond drive link 2150, is mounted to the distal end of the secondparallel link 2190. Similarly, the second parallel link 2190 isrotatably repositionable with respect to the second jaw 2250 along acommon axis longitudinally aligned with an eighth pin 2300 thatconcurrently extends through the second parallel link and the secondjaw.

In this exemplary end effector 2100, the jaws 2240, 2250 arerepositioned toward and away from one another while maintaining aparallel orientation. In order to reposition the first and second jaws2240, 2250 with respect to one another, the first and second drive links2140, 2150 as well as the first and second parallel links 2180, 2190 arerotated with respect to the linkage housing 2130. To facilitate thisrepositioning of the jaws 2240, 2250 with respect to one another, thedistal ends of the first and second toggles 2200, 2210 are mounted tomedial portions of respective drive links 2140, 2150. In particular, thedistal end of the first toggle 2200 is mounted to a medial portion ofthe first drive link 2140 via a ninth pin 2310. Accordingly, the firsttoggle 2200 is rotatably repositionable with respect to the first drivelink 2140 along a common axis longitudinally aligned with the ninth pin2310. In addition, the distal end of the second toggle 2210 is mountedto a medial portion of the second drive link 2150 via a tenth pin 2320.Consequently, the second toggle 2210 is rotatably repositionable withrespect to the second drive link 2150 along a common axis longitudinallyaligned with the tenth pin 2320. A more detailed discussion of thecomponent parts of the end effector 2100 follows.

As shown in FIGS. 20-22, the linkage housing 2130 includes a pair ofelongated projections 2510 extending outward from a trapezoidal block2511 extending laterally, proximally, and distally offset from a midlineand from opposing top and bottom exterior surfaces 2512 of the linkagehousing. In this exemplary embodiment, the projections 2510 include aplateau surface 2514 that is generally planar and angled other thanparallel with respect to the planar top/bottom surface 2512. Aperipheral shape of each projection 2510 is rectangular on a proximalend 2513 and is rounded on a distal end 2515 and generally centered withrespect to the trapezoidal block 2511. In particular, a peripheralsurface 2516 of each projection 2510 has a substantially constant heightfrom distal to proximal to provide a uniform height of the projection2510 proximal to distal.

A proximal end 2522 of the linkage housing 2130 is semicircular inprofile. In particular, the proximal end 2522 includes a miniaturechannel 2526 that terminates at a corresponding through opening 2546extending into an interior of the linkage housing 2130. The throughopening 2546 extends distally and terminates in between a pair of innerarms 2534, 2536. The central through opening 2546 is sized toaccommodate a control wire 3364 coupled to the pulley 2220 (see FIG.17). As will be discussed in more detail hereafter, repositioning of thepulley 2220 with respect to the linkage housing 2130 results incomponent motion operative to increase or decrease the distance betweenthe opposing jaws 2240, 2250 responsive to components being pivotallyconnected to a pair of outer retention arms 2530, 2532 and the innerarms 2534, 2536.

In exemplary form, the outer retention arms 2530, 2532 each include arespective interior wall surface 2552 that provides a camming surfaceagainst which the parallel links 2180, 2190 rotate. In this exemplaryembodiment, the interior wall surfaces 2552 are planar and parallel toone another. A distal orifice 2568 extends through the entire outerretention arm 2530, 2532. The distal orifice 2568 is sized toaccommodate one of the second pin 2170 and the third pin 2230 in orderto allow pivotal motion between the linkage housing 2130 and theparallel links 2180, 2190. By way of example, the distal orifices 2568of the outer retention arms 2530, 2532 are cylindrical and have axialcenters that lie along a common axis. In addition to the distal orifice,each outer retention arm 2530, 2532 also includes a proximal orifice2570 that extends entirely through the outer retention arm. The proximalorifice 2570 is sized to accommodate the first pin 2160 in order toallow pivotal motion between the linkage housing 2130 and the drivelinks 2140, 2150. By way of example, the proximal orifices 2570 of theouter retention arms 2530, 2532 are cylindrical and have axial centersthat lie along a common axis.

The inner arms 2534, 2536 extend distally and are generally parallelwith the outer retention arms 2530, 2532, with spacing between each setof adjacent arms. In exemplary form, the inner arms 2534, 2536 eachinclude a single hole 2580 that extends laterally through the arm and iscylindrical in shape. A central axis extending through each hole 2580 iscoaxial with the counterpart central axis of the other hole. Likewise,the central axis of the holes 2580 is coaxial with the common axis ofthe proximal orifices 2570 so that the holes and orifices are sized toaccommodate the first pin 2160 in order to allow pivotal motion betweenthe linkage housing 2130 and the drive links 2140, 2150 (compare FIGS.17 and 18). The spacing between the arms 2534, 2536 allows forproximal-to-distal motion of the pulley 2220 therebetween, whileprohibiting motion of the toggles 2200, 2210 therebetween. Rather, thefirst arm 2534 includes a triangular projection extending distally, thehypotenuse of which comprises a first surface 2582 that is angled togenerally face the top surface 2512. Similarly, the second arm 2536includes a triangular projection extending distally, the hypotenuse ofwhich comprises a second surface 2584 that is angled to generally facethe bottom surface 2512. In this exemplary embodiment, the surfaces2582, 2584 are perpendicular to one another and, as will be discussed inmore detail hereafter, the toggles 2200, 2210 contact these surfaces inorder to limit repositioning of the toggles as the pulley 2220 isrepositioned.

Referencing FIGS. 19 and 23-25, the first and second drive links 2140,2150 as well as the first and second parallel links 2180, 2190 arerotationally repositionable and mounted to the linkage housing 2130. Inexemplary form, the first and second drive links 2140, 2150 arestructurally identical, but differ only in operation based upon thecomponents mounted thereto. Consequently, the following discussion ofthe structure of a drive link is applicable to both the first and seconddrive links 2140, 2150.

Each drive link 2140, 2150 comprises a unitary structure including apair of spaced apart, tilted uprights 2590, 2592 that are angledapproximately forty-five degrees with respect to correspondinglongitudinal extensions 2594, 2596. The base of the uprights 2590, 2592are joined to one another via a bridge 2598. In exemplary form, eachupright 2590, 2592 includes a rounded proximal end 2600 that interposesopposing planar surfaces 2604, 2606. Extending completely through eachupright 2590, 2592 is a hole 2610 partially bounded by the opposingplanar surfaces 2604, 2606 and having a cylindrical shape that is sizedto accommodate throughput of the first pin 2160 and allow rotationalrepositioning of each upright around the first pin. Each upright 2590,2592 also includes a step 2612 recessed distally beyond the proximal end2600 and the hole 2610. The step 2612, as will be discussed in moredetail hereafter, is inset to approximately half of the thickness of thewidest portion of the upright 2590, 2592. Extending distally from thestep 2612, each upright 2590, 2592 seamlessly transitions into arespective longitudinal extension 2594, 2596. The bridge 2598 ispositioned approximate the transition region between the uprights 2590,2592 and the longitudinal extensions 2594, 2596 and recessed withrespect to bottom planar surfaces 2614 of the longitudinal extensions.On the top side 2616 of each drive link 2140, 2150, the bridge 2598seamlessly transitions into the longitudinal extensions 2594, 2596 anembodies an arcuate, convex longitudinal profile so that the top of eachlongitudinal extension includes a longitudinal ridge 2618 extending fromthe bridge 2598 distally toward a distal rounded end 2620 of eachlongitudinal extension. Along the longitudinal length of eachlongitudinal extension 2594, 2596 is a pair of openings 2622, 2624extending completely through the longitudinal extensions betweenopposing lateral inner and exterior sides 2628, 2630. Each opening 2622,2624 has a cylindrical shape and is configured to receive at least oneof the fifth, sixth, ninth, and tenth pins 2260, 2270, 2310, 2320. Inthis fashion, the first and second toggles 2200, 2210 as well as thefirst and second jaws 2240, 2250 may be rotationally repositionable withrespect to one of the drive links 2140, 2150.

Referring to FIGS. 19 and 32-34, the first and second toggles 2200, 2210as well as the first and second jaws 2240, 2250 are rotationallyrepositionable and mounted to the drive links 2140, 2150. In exemplaryform, the first and second toggles 2200, 2210 are structurallyidentical, but differ only in operation based upon the componentsmounted thereto. Consequently, the following discussion of the structureof a toggle is applicable to both the first and second toggles 2200,2210.

Each toggle 2200, 2210 comprises a unitary structure including toggleconnector portion 2640 and a drive link connector portion 2642. Inexemplary form, the toggle connector portion includes a rounded end 2644with a substantially constant width that is approximately half of thewidth of the drive link connector portion 2642. Along the longitudinallength of the toggle connector portion 2640, an arcuate profile exists.This toggle connector portion 2640 includes a through opening 2646having a cylindrical shape and configured to receive a cylindricalprojection of the pulley 2220 so that the toggle 2200, 2210 isrotationally repositionable about the pulley 2220.

Opposite the toggle connector portion 2640, the drive link connectorportion 2642 includes an offset 2648 extending widthwise beyond thewidth of the toggle connector. An opening 2650 extends through the drivelink connector portion 2642 and the offset 2648 having a cylindricalshape and configured to receive one of the ninth and tenth pins 2310,2320 so that the toggle 2200, 2210 is rotationally repositionable abouta drive link 2140, 2150. A partial circumferential groove 2652 exists onthe rounded end 2654 of the drive link connector portion 2642. Thisgroove 2652 is configured to receive a portion of a deployment wire3402, 3404 (see FIG. 39) in order to allow the deployment wire tocontact and be unimpeded by motion of the toggle 2200, 2210 when thetoggle is repositioned and/or when the deployment wire is repositionedwith respect to the jaws 2240, 2250 in order to detach, for example, aleft atrial occlusion clip 2102 temporarily mounted to the jaws.

As shown in FIGS. 26 and 27, the jaws 2240, 2250 are structurally mirrorimages of one another. Consequently, the following discussion of thestructure of a jaw is generally applicable to both the first and secondjaws 2240, 2250.

Each jaw 2240, 2250 includes a rounded proximal end 2660 thattransitions distally into a rectangular cross-section with a pair ofopenings 2662, 2664 extending between opposing top and bottom surfaces2666, 2668 each having a cylindrical shape and being configured toreceive at least one of the fifth, sixth, seventh, and eighth pins 2260,2270, 2290, 2300 (see FIG. 19). In this fashion, the first and secondjaws 2240, 2250 may be rotationally repositionable with respect to thedrive links 2140, 2150 and the parallel links 2180, 2190. Therectangular cross-section also includes one of a series of openings 2670on an interior surface 2672 in communication with a plurality ofopenings 2674 and channels 2676 formed into the opposing exteriorsurface 2678. In this exemplary embodiment, the channels 2676 are sizedand configured to receive a respective deployment wire 3402, 3404,whereas the openings 2670, 2674 are sized to accommodate throughput of asuture retainer coupled to the left atrial occlusion clip 2102. Theinterior surface 2672 also has formed therein a LAA spring depression2676 sized and configured to receive a biasing spring of the left atrialocclusion clip 2102 (see FIG. 37). This LAA spring depression 2679 is incommunication with a longitudinal depression 2677 formed into theinterior surface 2672 and the bottom surface 2668. And this longitudinaldepression 2677 is sized and configured to receive occlusion bars of theleft atrial occlusion clip 2102. Each jaw 2240, 2250 taperslongitudinally from proximal to distal after passing beyond the LAAspring depression 2679 to terminate at a rounded distal end 2680. Aspart of repositioning the jaws 2240, 2250 with respect to one another,the parallel links 2180, 2190 are also repositioned with respect to oneanother.

Referring to FIGS. 19 and 28-31, the first and second parallel links2180, 2190 are structurally identical, but differ only in operationbased upon the components mounted thereto. Consequently, the followingdiscussion of the structure of a parallel link is applicable to both thefirst and second parallel links 2180, 2190.

Each parallel link 2180, 2190 comprises a unitary structure including apair of spaced apart heads 2700, 2702 that are angled approximatelyforty-five degrees with respect to corresponding longitudinal legs 2704,2706. Near a base, the heads 2700, 2702 are joined to one another via alink 2710. In exemplary form, each head 2700, 2702 includes a taperedproximal end 2714, which is rounded at a far proximal tip, that includesa hole 2716 partially bounded by opposing interior and exterior planarsurfaces 2718, 2720, as well as an arcuate exterior surface 2722. Thehole 2716 has a cylindrical shape that is size to accommodate throughputof at least one of the seventh and eighth pin 2290, 2300 and allowrotational repositioning of a respective parallel link 2180, 2190 arounda respective jaw 2240, 2250. Each head 2700, 2702 includes an S-shapedprofile 2722 on one widthwise side that is configured to track aninverse S-shaped profile 2724 associated with an opposite side of thesame head 2700, 2702. In this fashion, as shown in FIG. 31 when theparallel links 2180, 2190 are positioned adjacent one another and thejaws 2240, 2250 are least spaced apart, the S-shaped contour 2722 of oneside of the first head 2700 of the first parallel link 2180 tracks theinverse S-shaped contour 2724 of a second side of the second head 2702of the second parallel link 2190. Each head 2700, 2702 also includes awidth that is roughly twice the width of the corresponding longitudinallegs 2704, 2706. In this fashion, the portion of heads 2700, 2702 withthe inverse S-shaped profile 2724 is offset in a widthwise dimensionfrom the corresponding longitudinal leg 2704, 2706.

The corresponding longitudinal legs 2704, 2706 extend parallel andspaced apart from one another in the widthwise direction. The onlymeaningful difference between the corresponding longitudinal legs 2704,2706 is that the first longitudinal leg 2704 includes a widthwise offset2728 that extends away from the second longitudinal leg 2706 proximatethe rounded distal tip 2730. Each longitudinal leg includes parallel,planar inner and outer surfaces 2732, 2734. A first hole 2736 extendsthrough the second longitudinal leg 2706 proximate the distal tip 2730,that is generally equidistantly spaced from the distal tip 2730 andcorresponding upper and lower surfaces 2740, 2742. The first hole 2736has a cylindrical shape and is configured to receive at least one of thesecond and third pins 2170, 2230 in order to allow the parallel links2180, 2190 to rotate with respect to the linkage housing 2130. A secondhole 2746 extends through the first longitudinal leg 2704 and offset2728 proximate the distal tip 2730, that is generally equidistantlyspaced from the distal tip 2730 and corresponding upper and lowersurfaces 2740, 2742. The second hole 2746 has a cylindrical shape and isconfigured to receive at least one of the second and third pins 2170,2230 in order to allow the parallel links 2180, 2190 to rotate withrespect to the linkage housing 2130.

Referring to FIGS. 17-40, an exemplary assembly sequence for theexemplary end effector 2100 will now be described. Initially, thecontrol and deployment wires 3164, 3402, 3404 are routed through theopening 2546 of the linkage housing 2130. At this point, the tilteduprights 2590, 2592 of the drive links 2140, 2150 are offset and alignedwith one another to fit between the linkage housing 2130 proximate theorifices 2570. More specifically the holes 2610 of the tilted uprights2590, 2592 are longitudinally aligned with the holes 2580 and theorifices 2570 of the linkage housing 2130 in order to receive the firstpin 2160, which extends completely through the linkage housing and thedrive links 2140, 2150.

The toggles 2200, 2210 are also mounted to a respective drive link 2140,2150, as well as concurrently to the pulley 2220. Specifically, thethrough opening 2650 of the first toggle 2200 is oriented between andcoaxially aligned with the openings 2622 extending through the firstdrive link 2140. When aligned, the ninth pin 2310 is inserted throughthe openings 2622, 2650 to mount the first toggle 2200 to the firstdrive link 2140. Similarly, the through opening 2650 of the secondtoggle 2210 is oriented between and coaxially aligned with the openings2622 extending through the second drive link 2150. When aligned, thetenth pin 2320 is inserted through the openings 2622, 2650 to mount thesecond toggle 2210 to the second drive link 2150. The opposing ends ofthe toggles 2200, 2210 are mounted to opposing ends of the pulley 2220.More specifically, each toggle through opening 2646 receives arespective cylindrical lateral end of the pulley 2220 in order torotationally mount the toggles 2200, 2210 to the pulley. At this time,the pulley 2220 is also mounted to the control wire 3364 so thatrepositioning of the control wire in tension is operative to repositionthe pulley and correspondingly other components in order to move thejaws 2240, 2250 toward or away from one another in a parallel open/closefashion.

Each jaw 2240, 2250 is then mounted to a respective drive link 2140,2150, and parallel link 2180, 2190. In exemplary form, a first of theopenings 2662 of a respective jaw 2240, 2250 is aligned with arespective opening 2624 of a respective drive link 2140, 2150. Afterbeing aligned, a fifth pin 2260 and a respective sixth pin 2270 areinserted through the openings 2624, 2662 in order to pivotally mount ajaw 2240, 2250 to a respective drive link 2140, 2150. Similarly, asecond of the openings 2664 of a respective jaw 2240, 2250 is alignedwith a respective hole 2716 of a respective parallel link 2180, 2190.After being aligned, a seventh pin 2290 and a respective eighth pin 2300is inserted through the openings 2664, 2716 in order to pivotally mounta jaw 2240, 2250 to a respective parallel link 2180, 2190. Also, theopposing ends of the parallel links 2180, 2190 are offset and alignedwith one another to fit between the linkage housing 2130 proximate theorifices 2568. When aligned, second and third pins 2170, 2230 aremounted to individual ends of the parallel links 2180, 2190 and to thelinkage housing 2130 to provide for pivotal motion between the parallellinks and the linkage housing. Before, during, or after mounting thejaws 2240, 2250 to the drive links 2140, 2150 and the parallel links2180, 2190, the deployment wires 3402, 3404 are respectively directedthrough openings 2674 of the jaws 2240, 2250.

The following comprises a description of exemplary processes forutilizing the exemplary end effector 2100. Initially, an incision ismade on either the left or right side of the chest wall in anintercostal space that is appropriate for the desired angle of approachto a left atrial appendage (LAA). The incision may be made through thechest wall or through the abdomen (or through the back) as part ofvarious procedures that include, without limitation, an open sternotomy,a left thoracotomy, a right thoracotomy, a left port, a right port, asubxiphoid approach, and a transdiaphragmatic approach. Post incision, atrocar (e.g., 10 mm or larger) may be inserted through the incision toextend into the thoracic cavity. In certain instances, it may bepreferred to insufflate the thoracic space subsequent to trocarinsertion using known techniques. Using at least one of the incision andtrocar, surgical instruments are introduced into the thoracic space inorder to perform a series of dissections, including dissection of thepericardium, to provide egress to the LAA. After having access to theLAA, the end effector 100 of the surgical tool 10 may be inserted intothe thoracic cavity by way of the incision or trocar.

The end effector 2100 is passed through the trocar or incision and arobotic instrument or other means is used to navigate the end effectorproximate the LAA. After navigating the LAA occlusion clip 2102proximate the LAA, the occlusion clip 2102 is opened prior to deploymenton the LAA.

Opening the LAA occlusion clip 2102 is carried out while a first roboticarm 4000 is coupled to the linkage housing 2130. More specifically, thefirst robotic arm 4000 includes a grasper 4010 comprised of a pair ofrepositionable, fenestrated jaws. In exemplary form, each opening of thefenestrated jaws is sized to circumscribe one of the elongatedprojections 2510 so that clamping of the fenestrated jaws clamps down onthe trapezoidal block 2511 is operative to mount the end effector 2100to the first robotic arm 4000 in a relatively secure positionsubstantially free from significant play. While the first robotic arm4000 is coupled to the end effector 2100, a second robotic arm 4020 andits grasper 4030 is repositioned to grasp an end of the control wire3364 and thereafter moved away from the end effector 2100 to tension thecontrol wire 3364, causing the end effector 2100 to further separate itsjaws 2240, 2250 from one another and open the clip 2102. Morespecifically, tensioning the control wire 3364 is operative toreposition the pulley 2220 proximally. Because a respective cylindricallateral end of the pulley 2220 is received in a through opening 2646 ofa respective toggle 2200, 2210, when the pulley 2220 is repositionedproximally, so too are the toggles repositioned proximally (toward thelinkage housing 2130) as well as rotating about an axis extendingthrough the opening 2646. In particular, the proximal motion androtation of the toggles 2200, 2210 operates to push against the firstand second drive links 2140, 2150 via the ninth and tenth pins 2310,2320 causing the drive links to move away from one another. But theconnection between the first and second drive links 2140, 2150 and thelinkage housing 2130, via the first pin 2160, causes the drive links topivot with respect to the linkage housing about the first pin when thedrive links are attempted to be moved away from one another via themotion of the toggles 2200, 2210.

The pivoting motion of the drive links 2140, 2150 is transferred to thejaws 2240, 2250 via the connection therebetween, facilitated by thefifth and sixth pins 2260, 2270. More specifically, the pivoting of thedrive links 2140, 2150 away from one another causes the jaws 2240, 2250to move away from one another. But the movement of the jaws 2240, 2250away from one another is constrained by the connection of the jaws tothe first and second parallel links 2180, 2190, which are themselvespivotally mounted to the linkage housing 2130. The additional constraintoffered by the parallel links 2180 results in motion of the jaws 2240,2250 that maintains the jaws in a generally parallel relationship as thejaws are moved from a closed position (adjacent one another with spacingto accommodate the clip 2102) to a fully open position (spaced away fromone another to open the clip to a predetermined maximum extent necessaryto position the clip on a LAA). This fully open position of the jaws2240, 2250 coincides with the surface of the toggle connector portions2640 contacting the first and second surfaces 2582, 2584 of the innerarms 2534, 2536, thus stopping further proximal and pivoting motion ofthe toggles 2200, 2210. In other words, the inner arms 2534, 2536 of thelinkage housing 2130 operate to limit the travel of the toggles 2200,2210, thereby setting the maximum spacing between the jaws 2240, 2250 ina fully open position.

As long as the jaws 2240, 2250 are attached to the occlusion clip 2102,the motion of the jaws results in corresponding motion of the occlusionclip. More specifically, when the jaws are in a closed position (seeFIG. 18) and mounted to the occlusion clip 2102, the bias of theocclusion clip retains the jaws in the closed position. But when onewants to open the occlusion clip 2102 in anticipation of positioning theclip around a LAA, one must overcome the bias of the occlusion clip. Inorder to do this, the end effector 2100 incorporates structures thatprovide a mechanical advantage allowing the user to tension the controlwire 3364, which as discussed in greater detail previously, ultimatelycausing the jaws 2240, 2250 to separate from one another andcorrespondingly separate the parallel beams of the occlusion clip 2102from one another.

Post opening of the LAA occlusion clip 2102, the first robotic arm 4000and grasper 4010, as well as the second robotic arm 4020 and its grasper4030, are moved in concert to reposition the end effector 2100 andadvance the clip 2102 over the distal tip of the LAA with the LAApassing between corresponding occlusion beams of the clip, stopping onlyupon reaching the base of the LAA. It should be noted that forceps maybe used to grasp a portion of the LAA when positioning the LAA occlusionclip 2102. After the clip 2102 has been positioned at the base of theLAA, with the LAA interposing corresponding occlusion beam surfaces ofthe clip, the user may close the clip 2102 to sandwich the LAA betweenthe occlusion surfaces.

Closing the LAA occlusion clip 2102 is also carried out by decreasingthe tension on the control wire 3364, thereby allowing the bias of theclip 2102 to cause the jaws 2240, 2250 of the end effector 2100 movingcloser to one another, thus sandwiching the clip around the LAA. Morespecifically, the second robotic arm 4020 and its grasper 4030 isrepositioned toward the end effector 2100 to decrease the tension on thecontrol wire 3364. By decreasing the tension of the control wire 3364,the bias of the clip 2102 dominates and causes jaws 2240, 2250 (whichare mounted to the clip 2102) to be repositioned toward one another,coinciding with closing of the occlusion clip 2102. In exemplary form,the dominant biasing force of the occlusion clip 2102 is operative toreposition the jaws 2240, 2250, which in turn causes the first andsecond drive links 2140, 2150 to pivot toward one another, coincidingwith the parallel links 2180, 2190 pivoting toward one another.Likewise, the toggles 2200, 2210 are pivoted and repositioned distally,as is the pulley 2220, ultimately leading to the component positionsshown in FIG. 18.

After the occlusion clip 2102 is positioned about the LAA, various stepsmay be undertaken to ensure the entire periphery of a portion of LAA issandwiched by the clip 2102 such as, without limitation, direct visualverification and utilization of a transesophageal echocardiogram. If anyproblems are determined with respect to the clip 2102 placement, theopening and closing clip sequence may be repeated to adjust thepositioning of the clip with respect to the LAA. Upon closing the LAAocclusion clip 2102 around a periphery of a portion of the LAA,proximate the LAA base, as well as confirming the placement of theclosed clip being operative to occlude the LAA, the surgeon may releasethe occlusion clip from the end effector 2100.

To release the clip 2102 from the end effector 2100, the second roboticarm 4020 and its grasper 4030 releases the control wire 3364 and graspsthe deployment wires 3402, 3404. Post grasping of the deployment wires3402, 3404, the second robotic arm 4020 and its grasper 4030 is movedaway from the end effector 2100 to tension the deployment wires andreposition the deployment wires proximally, ultimately leading todiscontinuing engagement with the suture loops 3412. When engagementbetween the suture loops 3412 and the deployment wires 3402, 3404 isdiscontinued, the occlusion clip 2102 is no longer fastened to the jaws2240, 2250 (i.e., the jaws can be opened and closed withoutrepositioning the clip). After disengagement between the occlusion clip2102 and the end effector 2100, the end effector may be removed from thecardiac space, as well as the deployment wires 3402, 3404 using thefirst and second robotic arms 4000, 4020.

Removal of the end effector 2100 from the patient's body may becontrolled by repositioning of the first robotic arm 4000. Because theend effector 2100 is open-ended, there is no need to reposition the endeffector upward along the LAA because the end effector can be withdrawnlaterally, thus reducing the potential for contact between the endeffector and the LAA. In other words, the end effector 2100 may beremoved from around the LAA without having a tip of the LAA passingbetween the jaws 2240, 2250. As part of removing the end effector 2100from the cardiac and thoracic space, the first robotic arm 4000 may bewithdrawn from the patient's body cavity via the incision or trocarwhile coupled to the end effector 2100.

Following from the above description and invention summaries, it shouldbe apparent to those of ordinary skill in the art that, while themethods and apparatuses herein described constitute exemplaryembodiments of the present invention, it is to be understood that theinventions contained herein are not limited to the above preciseembodiment and that changes may be made without departing from the scopeof the invention as defined by the following proposed points of novelty.Likewise, it is to be understood that it is not necessary to meet any orall of the identified advantages or objects of the invention disclosedherein in order to fall within the scope of the invention, sinceinherent and/or unforeseen advantages of the present invention may existeven though they may not have been explicitly discussed herein.

What is claimed is: 1-18. (canceled)
 19. A necrosis clip and appliercomprising: an open-ended necrosis clip comprising a first beamlongitudinally aligned with and spaced apart from a second beam, thefirst beam operatively coupled to and longitudinally aligned with athird beam, the second beam operatively coupled to and longitudinallyaligned with a fourth beam, where the third and fourth beams are coupledto one another, and where the first and second beams each include anunattached terminal end; an end effector including a first jaw and asecond jaw repositionably mounted to a housing, the first and secondjaws operatively coupled to at least a gun tackle pulley configurationutilized to reposition at least one of the first and second jaws withrespect to one another, where the first and second jaws are detachablymounted to the open-ended necrosis clip; and, a robotic coupling featureassociated with the end effector and configured to be engaged by arobotic surgical instrument to removably couple the robotic surgicalinstrument to the end effector.
 20. The necrosis clip and applier ofclaim 19, wherein the robotic coupling feature includes at least one ofa cavity and a projection configured to be engaged by the roboticsurgical instrument.
 21. The necrosis clip and applier of claim 19,wherein: the end effector includes a first detachment line in operativeengagement with the first jaw of the end effector and the necrosis clip;and, the end effector includes a second detachment line in operativeengagement with the second jaw of the end effector and the necrosisclip.
 22. The necrosis clip and applier of claim 21, wherein the firstjaw and the second jaw each include a channel configured to receive atleast one of the first detachment line and the second detachment line.23. The necrosis clip and applier of claim 21, wherein: the firstdetachment line extends through a first loop coupled to the first jawwhen the open-ended necrosis clip is detachably mounted to the firstjaw; the second detachment line extends through a second loop coupled tothe second jaw when the open-ended necrosis clip is detachably mountedto the second jaw; the first detachment line does not extend through thefirst loop coupled to the first jaw when the open-ended necrosis clip isdetached from to the first jaw; and, the second detachment line does notextend through the second loop coupled to the second jaw when theopen-ended necrosis clip is detached from to the second jaw.
 24. Thenecrosis clip and applier of claim 23, wherein: the first jaw includes afirst channel configured to receive the first detachment line; the firstjaw includes a first orifice configured to receive the first loop; thesecond jaw includes a second channel configured to receive the seconddetachment line; and, the second jaw includes a second orificeconfigured to receive the second loop.
 25. The necrosis clip and applierof claim 19, wherein: at least the gun tackle pulley configurationincludes a first pulley, a second pulley, and a third pulley; the firstjaw is mounted to the first pulley and the third pulley; the second jawis mounted to the second pulley; and, the line is fixedly coupled to thesecond jaw and repositionably engages the first pulley, the secondpulley, and the third pulley.
 26. The necrosis clip and applier of claim19, wherein: at least the gun tackle pulley configuration includes afirst pulley, a second pulley, a third pulley, and a fourth pulley; thefirst jaw is mounted to the first pulley and the third pulley; thesecond jaw is mounted to the second pulley and the fourth pulley; and,the line is fixedly coupled to the first jaw and repositionably engagesthe first pulley, the second pulley, the third pulley, and the fourthpulley.
 27. The necrosis clip and applier of claim 19, wherein the firstjaw pivotally engages the second jaw.
 28. A method of deploying anocclusion clip comprising: inserting an open-ended occlusion clip withdual terminal ends removably mounted to an end effector through at leastone of an incision and a trocar, the end effector devoid of a handlecontrol, the open-ended occlusion clip and the end effector operativelycoupled to one another prior to insertion into and through at least oneof the incision and the trocar; repositioning the end effector using afirst robotic tool to reposition the open-ended occlusion clip so theopen-ended occlusion clip is interposed by a portion of a left atrialappendage between a base and a tip of the left atrial appendage withoutneeding to pass a tip of the left atrial appendage between opposingclamping surfaces of the open-ended occlusion clip and without needingto pierce the left atrial appendage; clamping the left atrial appendagewith the open-ended occlusion clip to cause necrosis to the left atrialappendage by repositioning a second robotic tool with respect to the endeffector; discontinuing operative coupling between the open-endedocclusion clip and the end effector; and, withdrawing the end effectorthrough at least one of the incision and the trocar.
 29. The method ofclaim 28, wherein the inserting step occurs during at least one of anopen sternotomy, a left thoracotomy, a right thoracotomy, a left portprocedure, a right port procedure, a subxiphoid approach, and atransdiaphragmatic approach.
 30. The method of claim 28, furthercomprising insufflating a thoracic space prior to the inserting step.31. The method of claim 28, further comprising: making an incision aspart of a procedure comprising at least one of an open sternotomy, aleft thoracotomy, a right thoracotomy, a left port procedure, a rightport procedure, a subxiphoid approach, and a transdiaphragmaticapproach; and, introducing a trocar through the incision.
 32. The methodof claim 28, wherein a first line is operatively coupled the endeffector.
 33. The method of claim 32, wherein: the end effector includesa first jaw operatively coupled to the open-ended occlusion clip; theend effector includes a second jaw operatively coupled to the open-endedocclusion clip; and, repositioning the end effector to reposition theopen-ended occlusion clip includes tensioning the first line to causeincreased spacing between the first jaw and the second jaw.
 34. Themethod of claim 28, further comprising grasping the left atrialappendage concurrent with repositioning the end effector deploymentdevice to reposition the occlusion clip so the open end of theopen-ended occlusion clip is interposed by the portion of the leftatrial appendage.
 35. The method of claim 28, further comprisingrepeating the repositioning and clamping steps prior to the disengagingstep.
 36. The method of claim 28, further comprising confirming aclamping position of the open-ended occlusion clip is operative to causenecrosis to the left atrial appendage using at least one ofvisualization and a transesophageal echocardiogram.
 37. The method ofclaim 28, wherein: the inserting step includes inserting the open-endedocclusion clip and the end effector through the trocar; the withdrawingstep includes withdrawing the end effector through the trocar; and, thetrocar comprises a twelve millimeter or less diameter cross-section. 38.(canceled)
 39. A method of deploying a necrosis clip comprising:inserting an open-ended necrosis clip having dual terminal ends,removably mounted to an end effector having repositionable jaws, throughat least one of an incision and a trocar, the open-ended necrosis clipbiased to a clamping position; repositioning the end effector tocounteract a bias of the open-ended necrosis clip, via repositioning afirst robotic tool, and repositioning the open-ended necrosis clip to atissue insertion position where less than a full bias of the open-endednecrosis clip would be applied to an inserted left atrial appendage;spatially repositioning the end effector using a second robotic armwhile the open-ended necrosis clip is in the tissue insertion positionso a portion of the left atrial appendage between a base and a tip ofthe left atrial appendage interposes opposing clamping surfaces of theopen-ended necrosis clip without having a tip of the left atrialappendage interpose the open-ended necrosis clip; and, repositioning theend effector, via repositioning the first robotic tool, to repositionthe open-ended necrosis clip from the tissue insertion position to atissue clamping position where the full bias of the open-ended necrosisclip is applied to the portion of the left atrial appendage tissue toinitiate necrosis of the left atrial appendage tip. 40-91. (canceled)